Can I appeal an insurance denial?

Yes. Under the Affordable Care Act, most health plans must allow you to file an internal appeal and, if denied, request an external review by an independent reviewer. According to HealthCare.gov, you typically have up to 180 days to file an internal appeal.

Why was my insurance claim denied?

Common reasons include lack of medical necessity, missing documentation, prior authorization issues, or services not covered under your policy. According to the Kaiser Family Foundation, approximately 20% of in-network claims were denied under ACA marketplace plans in 2023.

How long do I have to appeal an insurance denial?

According to HealthCare.gov, many health plans require internal appeals within 180 days (about 6 months) from the denial notice. External review requests often must be filed within 4 months of the final internal denial decision.

What happens if my appeal is denied?

If your internal appeal is denied, you have the right to request an external review by an independent third party. According to healthcare industry research, 60-80% of external reviews result in the denial being overturned, especially for medical necessity disputes.

Does this tool provide legal advice?

No. InsuranceAppeal.ai provides educational guidance only and does not provide legal or medical advice. For complex cases, consult a patient advocate or healthcare attorney.

How to Appeal a Medication Denial: Ozempic, Wegovy, Zepbound & Mounjaro

Had your GLP-1 medication denied? You're not alone. According to ENDO 2024 research,64% of GLP-1 prescriptions are denied for patients with obesity. This guide shows you how to appeal and get the medication you need.

Key Statistics: GLP-1 Medication Denials

64% denied — GLP-1 prescriptions for obesity-only patients (Endocrine Society ENDO 2024)
32% denied — GLP-1 prescriptions for type 2 diabetes patients (ENDO 2024)
39-59% appeal success — Internal appeals that succeed when properly documented (CNN Health)
85% never appeal — Despite high success rates when they do (CNN Health)

Get Your Personalized Medication Appeal Letter

Upload your denial letter and our AI tool will analyze it and generate a customized appeal letter specifically for your medication.

GLP-1 Medications and Insurance Coverage

Medication	FDA Approved For	Monthly Cost	Insurance Coverage
Ozempic	Type 2 diabetes	$968	Usually covered for diabetes
Wegovy	Weight loss, cardiovascular	$1,349	Mixed — many denials
Mounjaro	Type 2 diabetes	$1,069	Usually covered for diabetes
Zepbound	Weight loss	$1,060	Mixed — many denials

Sources: GoodRx, NAIC

Why GLP-1 Medications Get Denied

Weight Loss Plan Exclusion

Many employer plans explicitly exclude "weight loss drugs" or "treatment of obesity." According to KFF research, only ~25% of employers covered GLP-1s for weight loss in 2023.

Step Therapy Requirements

Insurers require trying cheaper medications first (like metformin or phentermine) before approving GLP-1s. Document failed prior treatments.

BMI Thresholds Not Met

Many plans require BMI ≥35 or ≥30 with comorbidities. Some have increased thresholds to reduce approvals.

Missing Documentation

Lack of documented lifestyle modifications, weight history, or physician-supervised diet attempts.

"Not Medically Necessary"

Insurers argue obesity is a "lifestyle choice" despite FDA approval and clinical guidelines supporting these medications.

Good News: Wegovy Cardiovascular Approval (March 2024)

According to the FDA, Wegovy received approval in March 2024 for reducing cardiovascular risk (heart attacks and strokes) by 20% and death by 19%.

This approval may improve coverage for patients with heart disease and BMI ≥27. If you have cardiovascular risk factors, cite this approval in your appeal.

Step-by-Step: How to Appeal a Medication Denial

Document Medical Necessity

Work with your doctor to document your BMI history, weight-related health conditions (diabetes, hypertension, sleep apnea, heart disease), and previous weight loss attempts that failed.

Get a Letter of Medical Necessity

Ask your doctor to write a detailed letter explaining why this specific medication is necessary for your condition, why alternatives won't work, and citing clinical guidelines and FDA approval.

Document Failed Prior Treatments

If step therapy is required, document all previous medications and why they failed (side effects, lack of efficacy, contraindications). Include records of supervised diet programs.

Cite Clinical Guidelines and FDA Approval

Reference FDA approval, American Association of Clinical Endocrinology (AACE) guidelines, and American Diabetes Association (ADA) recommendations.

Submit Your Appeal Before the Deadline

According to HealthCare.gov, most plans require appeals within 180 days. Send via certified mail and keep copies.

Sample GLP-1 Medication Appeal Letter

[Your Name] [Your Address] [City, State ZIP] [Date] [Insurance Company Name] [Pharmacy Appeals Department] [Address] Re: Appeal of Medication Denial Policy Number: [Policy Number] Member ID: [Member ID] Medication: [Ozempic/Wegovy/Mounjaro/Zepbound] Denial Date: [Date] Dear Appeals Committee: I am writing to formally appeal the denial of coverage for [medication name]. Your letter dated [date] stated the medication was denied because [quote exact reason]. I believe this denial should be overturned because: MEDICAL NECESSITY: • My current BMI is [X], qualifying under FDA guidelines • I have the following obesity-related conditions: [diabetes/hypertension/sleep apnea/heart disease] • Previous weight loss attempts have failed, including [list prior treatments] • My physician has determined this medication is medically necessary CLINICAL EVIDENCE: • [Medication] is FDA-approved for [indication] • March 2024: Wegovy approved for 20% reduction in cardiovascular events • American Diabetes Association guidelines recommend GLP-1 agonists for [condition] ENCLOSED DOCUMENTATION: • Letter of medical necessity from Dr. [Name] • Weight history showing [X years] of documented obesity • Medical records documenting comorbidities • Records of failed prior treatments I respectfully request that you reconsider this denial and approve coverage for [medication]. Please contact my physician, Dr. [Name], at [phone] if you need additional information. Sincerely, [Your Name] [Phone Number]

Frequently Asked Questions: Medication Denials

What is the denial rate for GLP-1 medications?

According to ENDO 2024 research,64% of GLP-1 prescriptions for patients with obesity only are denied. The rate drops to 32% for patients with type 2 diabetes.

Do medication appeals work?

Yes. According to CNN Health, internal appeals succeed 39-59% of the time when properly documented. However, 85% of people never appeal.

Does Medicare cover weight loss drugs?

Currently, Medicare is explicitly banned from covering weight loss drugs (since 2003). However, the NAIC notes that advocacy efforts are ongoing to change this policy.

What if my plan has a weight loss exclusion?

If your plan explicitly excludes weight loss treatment, appeals typically won't work. However, if you have type 2 diabetes, the medication may be covered under diabetes treatment. Check with your employer's HR department about plan changes.

Ready to Appeal Your Medication Denial?

Upload your denial letter and get a personalized analysis with a ready-to-send appeal letter in minutes.

Related Appeal Guides

Complete Insurance Appeal Guide

Step-by-step guide for all insurance types

Prior Authorization Appeals

When prior auth is denied

About This Guide

This guide is provided for educational purposes only and does not constitute medical or legal advice. Statistics cited are from publicly available sources including the Endocrine Society, CNN Health, and NAIC.

Always work with your healthcare provider to determine the best treatment options for your condition.